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Correspondence to: Sumit Dave, Pediatric Urology Department of Surgery and Pediatrics, Children’s Hospital 800 Commissioners Road East, London, ON N6A 5W9, Canada, Tel.: +519 685 8439; fax: +519 667 6581
The transition from laparoscopic to robot-assisted procedures leads to potential increase
in operative times and health care costs. Cumulative sum (CUSUM) analysis can objectively
study the learning curve to detect significant changes in operative timing and monitor
The objective of this study is to investigate the total and step-specific times for
pediatric robot-assisted pyeloplasty (RAP) to investigate the learning curve of a
single surgeon transitioning from laparoscopic to RAP.
This prospective cohort study included 50 consecutive RAP procedures performed since
the inception of our robotic program from June 2013 to January 2019. The CUSUM of
RAP total operative time (OT) was calculated to determine the breakpoints between
learning phases using piecewise linear regression. Cumulative-observed-minus-expected
failure chart with 80% and 95% reassurance boundary lines was constructed using 5%
acceptable and 10% unacceptable complication rates. Step-specific operative times
were prospectively recorded by an independent observer for port placement, dissection
and hitch stitch placement, pelvis dismemberment and spatulation, suturing and port
Piecewise linear regression for OT identified breakpoints at case 13 and 29 suggesting
transition at these points between Learning to Proficiency, and Proficiency to Competency. The overall mean OT was 142.2 ± 46.0 min. There was a significant difference in
the mean OT between Learning (203.9 ± 35.3 min, the initial 13 cases), Proficiency (159.2 ± 18.6 min, the middle 16 cases), and Competency (126.6 ± 19.7 min, the last 21 cases) phases (p < 0.001). The complication rate for
RAP stabilized around the acceptable level of 5% up to case 41 before finalizing at
8% overall. The step-specific analysis suggested that suturing entered the Competency phase at case 27, with a 50% decrease in suturing time from Learning to Proficiency and Competency.
Our study suggests that by case 30 a surgeon transitioning to RAP can achieve a significant
decrease in OT. Complication rates remained within acceptable limits throughout, indicating
that RAP can be safely adopted, even in low volume RAP centres. Suturing competency
seems to be a significant advantage of the robotic platform as suggested by early
significant decrease in suturing times noted between the Learning and Proficiency phases.
In this issue of the Journal of Pediatric Urology, Stern et al. present on an experienced laparoscopic surgeon's experience in adopting the robotic-assisted platform for pediatric pyeloplasty . This manuscript can be read at multiple levels. First, the authors nicely demonstrate both overall and task-specific learning curves for surgeons adapting the robotic technique. While the robotic platform has already saturated many marketplaces, this is relevant work for those areas where the surgical robot still represents an emerging opportunity.